【作者】 阮陆宁；

【导师】 甘筱青；

【作者基本信息】 南昌大学 ， 管理科学与工程， 2012， 博士

【摘要】 随着社会进步与经济发展,医学技术和信息的发展以及人们对卫生服务期望的不断提高,我国卫生总费用中个人支出呈线性增长趋势,居民医疗负担不断加重。“看病难、看病贵”仍然是国民关注的重要问题。2009年国务院“关于深化医药卫生体制改革的意见”指出,“完善以社区卫生服务为基础的新型城市医疗卫生服务体系。加快建设以社区卫生服务中心为主体的城市社区卫生服务网络；建立城市医院与社区卫生服务机构的分工协作机制。”。近年来,我国社区卫生服务网络初步建立,但仍然存在问题与困难,医疗资源配置已成为我国社区卫生服务发展的突出问题。因此,构建、发展和完善社区卫生服务网络,有效配置区域医疗、上下游医疗机构间的医疗服务资源,使社区卫生服务机构与城市医院协调发展,是优化医疗资源配置、提高卫生资源使用公平性和效率性的需要。在城市社区卫生服务网络中,医疗机构的联结主要是通过转诊医疗活动来实现的,社区卫生机构与医院之间的双向转诊成为实现分级医疗的核心问题,借鉴发达国家的先进经验和解决问题的方法,结合我国国情,研究探索城市社区卫生服务网络的协调机制已成为迫切需要研究的课题。建立城市社区卫生服务网络是一个复杂的系统工程,其目标是实现社区卫生服务机构和城市医院的合作、有效地配置全社会的有限的医疗资源,从经济意义看是实现合作价值最大化,最终目的是实现人的健康。但究竟应该如何协调来实现是值得深入研究的问题。城市社区卫生服务网络的构成与运行涉及到患者、社区卫生服务机构、城市医院、医疗保险机构和政府等多个行为主体,作为城市医疗服务市场供给方的社区卫生服务机构与城市医院之间的行为分析是最基础的形式,从经济学和管理学角度看,本质上是经济行为主体的行为方式,通过查阅文献发现,近几年国内对社区卫生服务转诊的研究较多,大多数研究主要是对策研究,以定性分析和比较分析方法为主,缺乏深入的机理分析和实证分析,关于城市社区医疗服务供应链的研究文献尚未见。因此,从经济行为主体角度研究其行为关系,进而从经济组织角度研究城市社区卫生服务组织形式,对认识医疗服务市场的运行规律,进而认识城市社区卫生服务网络,具有理论意义和实际应用价值,本文从经济组织的视角,将研究聚焦于城市社区卫生服务网络,从社区卫生服务机构与城市医院的转诊关系入手,构建了城市社区医疗服务供应链网络,建立了城市社区医疗服务供应链网络协调的基本分析框架,提出了能力、信任和信息的治理机构,系统地探索性研究了城市社区卫生服务网络的协调问题；建立了具有医疗服务质量差异的Hotelling模型和Salop模型,对城市居民就医选择行为进行了分析；针对我国城市医院与社区卫生服务机构互动的三种协调模式,从关系租金角度进行了分析,分析结论表明纵向一体化模式是一种Pareto改进,而建立长期关系导向的关系契约模式优于纵向一体化模式；以医疗服务能力为协调要素,构建了城市社区医疗服务供应链网络的关系契约协调模型；研究了城市社区医疗服务供应链成员之间的信任关系问题,提出了建立城市社区医疗服务供应链成员之间信任的分析框架和建议；最后根据本文的研究提出了发展我国社区卫生服务网络的政策建议。本文运用卫生经济学,交易费用理论、关系契约理论等理论,构建了城市医疗服务供应链网络协调的基本分析框架,从微观层面、组织层面及制度层面系统地对城市社区卫生网络的协调问题进行了探索性研究,以期能够为我国医疗体制改革提供理论支持和实践依据。更多还原

【Abstract】 Social and economic progress has accelerated the development of medical technology and information and as well raised people’s expectations for health services. The linear increasing tendency of per capita spending in total health expenditure in China indicates that health service is a financial burden for most citizens."Being too difficult and too expensive to see the doctor" is still an important issue of national concern. State "proposals on deepening the medical and health service system" of2009advocate to "perfect the new community-based urban health service system, to speed up the construction of community health service centers as the framework of urban community health service network, and to establish the coordination mechanisms between urban hospitals and community health service centers "。In recent years, network of community health service has gradually established in China but there are still some problems and difficulties. The allocation of medical resource has become the leading problem in the development of community health service problem in China. Therefore, the construction, development and improvement of community health service network, the effective allocation of medical care resources between regions and between lower and upper medical institutions, and the coordinated development of community health service centers and urban hospitals, all these are essential measures for optimizing the allocation of medical resources and improving the fairness and efficiency of health services. In the urban community health service network, the connection between medical institutions is achieved mainly through referral medical activities. The bi-directional referral between community health service centers and hospitals thus becomes the key issue to realize the graded health services. Therefore research on the coordination mechanism of urban community health service network has become an urgent topic based on the advanced experiences of developed countries, combining with the present conditions in China.It is a complicated systems engineering to establish the urban community health service network for its target is to realize the cooperation between community health service institutions and effective allocation of the limited medical resources of urban hospitals, so as to maximize the value of cooperation from the economic perspective and ultimately to guarantee people’s health. But exact measures requires further research as to how such a target can be achieved with coordinated efforts.The construction and operation of urban community health service network involve many parties such as patients, community health service institutions, city hospitals, and medical insurance institutions and the local governments. Yet the behavioral relationship between community health service institutions and city hospitals, both as the suppliers of urban medical service market forms the most fundamental part of our analysis. From economic and managerial perspective, economic behavior is the essential form of behavior. But the literature reviews indicate that in recent years many studies mainly focused on referral activities within community health service centers and most researches are conducted under strategic analysis, qualitative analysis and comparison analysis. Fewer researches have conducted under mechanism analysis and empirical analysis on city community medical service supply chain network.Therefore, it is of theoretical significance and practical value to study the behavioral relationship between different forms of community health service from the perspective of economic agents, and thus from the perspective of economic organization research on urban community health service organization and operation law for better understanding of the medical service market and the urban community health service network.This research, from economic organization of perspective, focuses on urban community health service network, establishes the basic framework of analysis starting from the referral relationship between community health service institutions and city hospitals to construct urban community medical service supply chain network and realize the coordination within this network, proposes a managerial institution based on ability, and trust and information. This paper also conducts a systematic study on the coordination between urban community health service networks, establishes Hotelling Model and Salop Model to indicate the quality of medical service to analyze city residents’choices of medical services. As for the three coordinating patterns of interaction between city hospitals and community health service institutions in China, analysis is conducted from the perspective of relationship rent and concluded that vertical integration model is a Pareto Improvements, and establishing a long-term relationship-oriented relationship between compact mode better than vertical integration models; to medical service capability for coordinated elements, construction of urban community health service supply chain network of relational contract coordination model;In addition, this dissertation has studied the trust relationships between members of the community medical service supply chain network, proposed a framework and suggestions for the establishment of trust between members of the urban community health service supply chain network; Finally some strategic recommendations are offered based on this study for the development of community health service network in China.This dissertation applies health economics, theory of transaction cost theory, relational contract theory to form the basic framework for analysis of the coordination of urban medical service supply chain network, and conducts some studies from the micro level, the organization level and the system level on the coordination between urban community health service networks, with a view to providing certain theoretical support and practical basis for medical system reform in China.更多还原